Archives of Craniofacial Surgery

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64 Copyright © 2018 The Korean Cleft Palate-Craniofacial Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/

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Case

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Arch Craniofac Surg Vol.19 No.1, 64-67https://doi.org/10.7181/acfs.2018.19.1.64

INTRODUCTION

Soft tissue augmentation using hyaluronic acid (HA) fillers is

widely used to decrease facial lines and improve the appearance of

soft tissues. However, varying degrees of complications can occur

after HA filler injection [1,2]. Tissue necrosis due to interruption of

the vascular supply is an early complication that can be severe [3].

In the present study, we describe a patient with widespread skin

necrosis after HA filler injection in the glabellar area. Additional-

ly, we describe a unique flap design inspired by the double-oppos-

ing rotation-advancement f lap method used by Ransom and

Forehead reconstruction using modified double-opposing rotation-advancement flaps for severe skin necrosis after filler injection

Varying degrees of complications can occur after hyaluronic acid filler injections. Tissue necrosis due to interruption of the vascular supply is an early complication that can be severe. If the site of tissue necrosis due to the filler injection is the forehead, successfully reconstructing the region without distorting the key landmarks is challenging. We describe the case of a 50-year-old man who experienced widespread forehead skin necrosis after hyaluronic acid filler injection in the glabellar area. We successfully covered the forehead area with a 3×4-cm2 midline necrotic tissue using the modified double-opposing rotation-advancement flap method. Although modified double-opposing rotation-advancement flap closure has the disadvantage of leaving a longer scar compared to conventional double-opposing rotation-advancement flap closure, the additional incision line made along the su-perior border of the eyebrow aids in camouflaging the scar and decreases eyebrow distor-tion. Therefore, it is believed that the modified double-opposing rotation-advancement flap technique is an excellent tool for providing adequate soft tissue coverage and minimal free margin distortion when reconstructing widespread skin necrosis in the central mid-lower forehead that can occur after filler injection in the glabellar area.

Keywords: Forehead / Surgical flaps / Dermal filler

Jinwoo Kim, Woosuk Hwang

Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University School of Medicine, Busan, Korea

Jacono [4]. Using modified double-opposing rotation-advance-

ment flaps, it is possible to achieve adequate soft tissue coverage

and minimal free margin distortion when reconstructing wide-

spread skin necrosis in the central mid-lower forehead that can

occur after filler injection in the glabellar area.

CASE REPORT

A 50-year-old man presented as an outpatient to the Plastic Sur-

gery Department of Busan Paik Hospital. His main symptom was

worsening of skin necrosis immediately after a filler injection that

was administered 3 weeks prior at a local clinic to treat frown lines

in the glabellar area. Tissue necrosis progressed despite the initial

treatment including massage, warm compression, and hyaluroni-

dase injection (Fig. 1). The patient was treated as an outpatient for

Correspondence: Jinwoo KimDepartment of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University School of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 47392, KoreaE-mail: jinooda@hanmail.net

Received November 9, 2017 / Revised March 8, 2018 / Accepted March 8, 2018

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Jinwoo Kim et al. Surgical flaps for forehead reconstruction

2 weeks to confirm the necrosis margin and to facilitate wound

healing. Wound healing progressed, but secondary healing pro-

duced unacceptable scars. Therefore, he was admitted to the hos-

pital for reconstructive surgery (Fig. 2).

The patient underwent surgery under systemic anesthesia on

day 1 of admission. To effectively cover the 3×4-cm2 midline fore-

head skin defect that was created after removing necrotic tissue

and poorly healed granulation tissues, modified double-opposing

rotation-advancement flaps were designed. After adequate de-

bridement, the flaps were raised on the subgaleal plane. The upper

area of the eyebrow was released while partially releasing the skin

of the lower area. The elevated lower left flap was rotated to cover

the defect, and the upper left and upper right flaps were advanced

to the defect (Fig. 3).

Fig. 1. Approximately 3×4-cm2 skin defect due to necrosis on day 1. Skin necrosis occurred after the patient was administered a filler injection in the glabellar area 3 weeks previously.

Fig. 2. The necrosis margin was defined and the wound had partially healed at 2 weeks after the first visit. It was considered an unaccept-able scar.

A

B

Fig. 3. Modified double-opposing rotation-advancement flaps. (A) During surgery. (B) The conventional double-opposing rotation-advancement flap design (blue lines) was created to prevent eyebrow distortion while filling large defects by making an additional incision (purple line) along the supra eyebrow line. During the procedure, one flap is rotated toward the primary defect (Y to Y’), and the contralat-eral flaps are advanced to the secondary defect (X to X’, Z to Z’). A dotted line is a tangent on the curvilinear defect margin drawn paral-lel to the schematic pathway of frontal branch of the facial nerve. Blue lines make a sort of capital “T” with slightly curved crossbar (one line is drawn at approximately 60°–75° from the dotted line, the other line is drawn roughly parallel to the dotted line, with a gentle curve).

Archives of Craniofacial Surgery Vol. 19, No. 1, 2018

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Suturing using absorbable polyfilament (Vicryl; Ethicon,

Somerville, NJ, USA) with some pieces of fascia was performed in

deeper skin layers. A second suture layer was placed on the epider-

mis using a nonabsorbable monofilament (Mersilk, Ethicon).

Penrose drains were inserted (Fig. 4). There were no complica-

tions. The patient was discharged 10 days after surgery. It was

confirmed that forehead reconstruction was successful at 3

months postoperatively (Fig. 5).

DISCUSSION

Vascular compromise after soft tissue augmentation with inject-

able facial fillers is a complication that should be addressed post-

operatively. In particular, facial areas such as the glabellar area have

been reported to be at higher risk for necrosis due to compromised

blood flow attributable to the vascular anatomy of the area [5].

It has been reported that when filler-induced soft tissue necro-

sis is clinically suspected, various treatment approaches such as

heparin, corticosteroid, hyaluronidase, platelet-rich plasma, and

others are as effective as early interventions [5-7]. When necrosis

has progressed past the acute phase, reconstructive surgery should

be attempted.

The forehead is a facial region with distinct boundaries defined

by the hairline superiorly, eyebrows and frontonasal groove inferi-

orly, and temporal ridges laterally. Therefore, reconstructing the

region successfully without distorting the key landmarks is chal-

lenging [8]. Additionally, serious consideration should be given to

midline forehead reconstruction to prevent eyebrow distortion

(elevation of the medial eyebrows and medial displacement of the

eyebrows) and to preserve motor and sensory nerve functions [9].

Regarding reconstruction of skin defects of the lower forehead

or mid forehead near the glabellar area, Quatrano et al. [10] pro-

posed that primary repair should be performed if the reconstruc-

tion area is smaller than 2 cm2, the modified Burow’s advance-

ment f lap or A-to-T f lap should be used if the area is

approximately 2–5 cm2, and a bilateral advancement flap or full-

A

B

Fig. 4. Final closure. (A) During surgery. (B) The elevated lower left flap was rotated to cover the defect (Y-Y’), and the upper left and upper right flaps were advanced to the defect (X-X’, Z-Z’).

Fig. 5. Forehead reconstruction was successful at 3 months after sur-gery. Minimal eyebrow distortion occurred after surgery. The scar at the superior border of the eyebrow was almost invisible.

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Jinwoo Kim et al. Surgical flaps for forehead reconstruction

thickness skin graft should be used if the area is larger than 5 cm2.

However, when full-thickness necrosis of the central mid-lower

forehead skin occurs in an area as large as 10 cm2 (as in our pa-

tient), a bilateral advancement flap can distort the eyebrows, and a

skin graft may lead to wound contraction, poor color, and mis-

matched texture.

Ransom and Jacono [4] presented the double-opposing rota-

tion-advancement flap method modified from the orticochea

flap method as a versatile reconstructive option for small, medi-

um, and large forehead defects. However, there were limitations

regarding eyebrow distortion and covering forehead defects larger

than 10 cm2.

Accordingly, inspired by the double-opposing rotation-ad-

vancement flaps, we performed an additional incision along the

superior border of the eyebrow contralateral to that used during

the conventional approach. This unique flap design led to suc-

cessful reconstruction because durable soft tissue covering a fore-

head skin defect as large as 10 cm2 was created during a single

stage without altering the eyebrow position.

Although modified double-opposing rotation-advancement

flaps have the disadvantage of leaving a longer scar compared to

conventional approaches, the additional incision line made along

the superior border of the eyebrow was camouflaged by the eye-

brow. Therefore, it is believed that modified double-opposing ro-

tation-advancement flaps are an excellent tool for central mid-

lower forehead skin defect reconstruction.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

PATIENT CONSENT

The patients provided written informed consent for the publica-

tion and the use of their images.

REFERENCES

1. Andre P. Hyaluronic acid and its use as a “rejuvenation” agent in cos-metic dermatology. Semin Cutan Med Surg 2004;23:218-22.

2. Bachmann F, Erdmann R, Hartmann V, Wiest L, Rzany B. The spec-trum of adverse reactions after treatment with injectable fillers in the glabellar region: results from the Injectable Filler Safety Study. Derma-tol Surg 2009;35 Suppl 2:1629-34.

3. Schanz S, Schippert W, Ulmer A, Rassner G, Fierlbeck G. Arterial em-bolization caused by injection of hyaluronic acid (Restylane). Br J Der-matol 2002;146:928-9.

4. Ransom ER, Jacono AA. Double-opposing rotation-advancement f laps for closure of forehead defects. Arch Facial Plast Surg 2012;14:342-5.

5. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase. Dermatol Surg 2007;33:357-60.

6. Tracy L, Ridgway J, Nelson JS, Lowe N, Wong B. Calcium hydroxylap-atite associated soft tissue necrosis: a case report and treatment guide-line. J Plast Reconstr Aesthet Surg 2014;67:564-8.

7. Kang BK, Kang IJ, Jeong KH, Shin MK. Treatment of glabella skin ne-crosis following injection of hyaluronic acid filler using platelet-rich plasma. J Cosmet Laser Ther 2016;18:111-2.

8. De Abullarade J. Aesthetic considerations in forehead reconstruction in skin carcinoma. J Cancer Ther 2013;4:20-3.

9. Baker SR. Local flaps in facial reconstruction. 3rd ed. Philadelphia: El-sevier; 2014.

10. Quatrano NA, Dawli TB, Park AJ, Samie FH. Simplifying forehead re-construction: a review of more than 200 cases. Facial Plast Surg 2016;32:309-14.